According to the WHO, about 40 million people are living with
HIV/AIDS globally. AIDS is the leading cause of death worldwide for
adults aged 15-49. In 2006, 4.3 million people were newly infected with
HIV and 2.9 million people died of HIV/AIDS-related illnesses.
Antiretroviral treatment (ART) has prolonged the survival of patients
infected with HIV-1. Morbidity and mortality related to HIV-1 have
dramatically declined in developed countries, converting HIV infection
into a treatable chronic disease. However, current antiviral drugs do
not eradicate the virus, and prolonged treatment can have serious side
effects and select for drug-resistant viral strains. However, just one
in five people at risk for HIV in sub-Saharan Africa has access to the
information and tools they need to prevent infection, and millions are
in urgent need of antiretroviral medicines. The WHO set the goal to stop
the spread of HIV/AIDS by 2015. The goal is feasible as HIV/AIDS is
preventable. Simply using condoms can make a big difference. Providing a
safe blood supply is another major step. Most important of all is
raising awareness about HIV/AIDS through community mobilization,
education program for AIDS prevention, and behavior change in special
groups. This review focuses on community-based interventions for
HIV/AIDS prevention.

Current antiviral drugs do not eradicate HIV, and prolonged
treatment can have serious side effects and select for drug-resistant
viral strains. (1,2) Most important of all is raising awareness about
HIV/AIDS through community mobilization, education program for AIDS
prevention, and behavior change in special groups. This review focuses
on community-based interventions for HIV/AIDS prevention.

Behavior Change Programs in Special Groups

Injecting drug users (IDUs)

A quasi-experimental study was conducted among IDUs in communities
located in urban areas in Sichuan Province, China. (3) A pair of sites
was selected; one site was the "intervention city" in which
various intervention measures were implemented, and the other was the
"control city" in which no intervention was implemented. A
Behavior Surveillance Survey was used to evaluate intervention exposure
and the effect of behavior change. In the intervention city, services
received by IDUs increased over time; awareness of HIV increased from
34.2% in 2003 to 58.3% in 2004, and to 67.4% in 2005. Overall needle
sharing decreased from 17.1% in 2003 to 7.0% in 2005, and needle sharing
in the past month decreased from 42.4% in 2003 to 18.4% in 2005. The
intervention was effective in changing this risk behavior. A Pakistani
group (4) reported a study conducted among 608 IDUs, of which 607 were
male, only one was female, the median age was 32 years old, and 45% had
no formal education. Half were married, of whom 25% were living with
their wives. With regard to sexual behavior, 14% had sex with other
males, 28% reported sex with both males and females, 49% had paid money
to have sex, and only 10% had ever used condoms. One-fifth reported
having had a sexually transmitted disease (STD) and about 40% reported
having suffered from either one or more STD-related symptoms. Only 41%
had heard about HIV/AIDS, of whom 17% knew that HIV/AIDS could be
transmitted through sexual contact. The authors concluded that high-risk
sexual behaviors are prevalent among male IDUs in Pakistan (5-6), and
awareness of transmission risks is low. Effective and specific
interventions in Pakistan are urgently needed to prevent the
transmission of HIV and STDs among IDUs and their sex partners. The
prevalence of HIV infection among IDUs in Saudi Arabia was reported for
the first time in a study of 2,628 men admitted to a rehabilitation
facility from January 1995 to May 1996 and who were screened for HIV-1
and/or HIV-2. (7) The study found that 81.2% of participants were aware
of HIV/AIDS and two-thirds knew that the virus can be transmitted by
sharing needles and syringes. Five samples were found to be positive by
enzyme immunoassay, but only four were confirmed by Western blot, for an
HIV prevalence of 0.15%. The low HIV prevalence detected in this study
among a high-risk group suggests that Saudi Arabia is in a pre-epidemic
stage. However, community-based data are necessary to establish the true
situation in the country. Continued public awareness campaigns on the
modes of HIV infection were recommended by the authors. IDUs in London
have made positive reductions in risk behavior. (8) Levels of syringe
sharing were substantially lower than those reported up to 1987 before
generalized AIDS awareness and the introduction of HIV prevention
measures. The majority did not share syringes or confined their sharing
to close friends and sexual partners, and when sharing, cleaned their
syringes. The continuation of indirect sharing indicates the need for
more detailed prevention messages. While the initial decline in syringe
sharing rates may be attributed to the wide availability of sterile
injecting equipment and other preventive measures, it may now be
necessary to look beyond current intervention initiatives to develop
interventions that seek to change the social etiquette of sharing and
move towards the long-term maintenance of low levels of injecting risk
behavior.

Female Sexual Partners Of IDUs

A participatory community project in the US-Mexico border town of
Ciudad Juarez aimed at helping women who are sex partners of male IDUs
to reduce behaviors that increase their risk of HIV infection. (9) The
design and implementation of the project were influenced by Paulo
Freire's pedagogy in the Latin American tradition of
'popular' education, by Bandura's self-efficacy concepts,
and by David Warner's 'barefoot doctor' community health
care methodology. Using these approaches, the participants were directly
involved in the development of teaching materials and curriculum
content, and implementation of the project. The program was evaluated
quantitatively using National Institute on Drug Abuse (NIDA's) AIDS
Intake and Follow-up Assessment (AIA/AFA) questionnaires and qualitative
open-ended interviews. While the AIA/AFA questionnaires detected small
changes in the frequency of condom use among the participants,
ethnographic interviews detected significant changes in the nature of
the behaviors that were placing the women at risk. The changes seemed to
stem from an increase in the degree of self-esteem, self-efficacy, and
awareness of the social, economic, and political constraints of their
lives. This study demonstrated the need for qualitative measures to be
incorporated in the evaluation of community-based health education
programs.

Female Sex Workers in the Entertainment Industry

Female sex workers at different sites in five different provinces
of China were targeted to evaluate STDs/HIV intervention program. (10) A
Women's Health Clinic was set up near participants' working
place at each site. Clinic-based outreach activities, including
awareness-raising, condom promotion, and sexual health care, were
developed and delivered to sex workers. Cross-sectional surveys at
baseline and post-intervention were used to evaluate changes in condom
use with the last three clients, and the prevalence of chlamydia and
gonorrhea. A total of 907 sex workers were examined at baseline; 12
months post-intervention, 782 were examined to measure the effect of the
intervention. Outreach teams made a total of 2552 visits to 13,785
female sex workers and distributed 33,575 copies of educational material
and 5,102 packets of condoms. The condom use rate increased from 55.2%
to 67.5%. The prevalence of gonorrhea fell from 26% to 4%; and that of
chlamydia fell from about 41% to 26%. The intervention was effective in
increasing condom use and reducing STDs among sex workers. The results
were used to develop national guidelines on sex worker interventions for
nationwide scale up.

Males In Rural Communities

In Goa, India, a sample of 300 males aged 15-49 years was selected
by stratified random sampling. (11) A cross-sectional community-based
survey was conducted following the "UNAIDS protocol for measurement
of HIV/STD prevention indicators." Of the men surveyed, 198
reported having sexual intercourse (66%) and 17% were single.
Fifty-three (17.7%) males reported intercourse with a non-regular
partner in the past 12 months; of these men, 90.6% had intercourse with
strangers, 92.5% had paid for sex, and only 43.4% had used a condom for
the last sexual encounter with a non-regular partner. Less educated
males (<10th grade), those who were single, and those who were
employed were more likely to have sex with non-regular sexual partners.
The level of knowledge about HIV/ AIDS was very high in all areas of
causation and prevention. Despite that, condom use was very low,
resulting in high-risk behavior related to HIV/AIDS and STDs among
males. The authors recommended more effective behavior change
communication (BCC) strategies in the community as well as innovative
methods like village level peer education. Behavioral change has also
been reported in a South African gold mining community (12) and among
fishermen in a coastal area of Balochistan. (13)

Educational Programs for AIDS Prevention

Peer Education Model for Low-Literacy Rural Communities

Low HIV awareness and high stigma, fueled by low literacy, seasonal
migration, gender inequity, spatial dispersion, and cultural taboos,
pose extra challenges to implementing much-needed HIV education programs
in rural areas. A peer education model was developed to educate and
empower low-literacy communities in the rural district of Perambalur
(Tamil Nadu, India). (14) From January to December 2005, six
non-governmental organizations (NGOs) with good community rapport
collaborated to build and pilot-test an HIV peer education model for
rural communities. The program used participatory methods to train 20
NGO field staff (outreach workers), 102 women's self-help group
(SHG) leaders, and 52 barbers to become peer educators. Cartoon-based
educational materials were developed for low-literacy populations to
convey simple, comprehensive messages on HIV transmission, prevention,
support, and care. In addition, street theater cultural programs
highlighted issues related to HIV and stigma in the community. The
program is estimated to have reached over 30,000 villagers in the
district through 2,051 interactive HIV awareness programs and one-on-one
communication. Outreach workers (OWs) and peer educators distributed
approximately 62,000 copies of educational material and 69,000 condoms,
and also referred approximately 2,844 people for services including
voluntary counseling and testing (VCT), care and support for HIV, and
diagnosis and treatment of sexually-transmitted infections (STIs). At
least 118 individuals were newly diagnosed as persons living with HIV
(PLHIV); 129 PLHIV were referred to the Government Hospital for Thoracic
Medicine (in Tambaram) for extra medical support. Focus group
discussions indicate that the program was well received in the
communities, led to improved health awareness, and also provided the
peer educators with increased social status. Using established networks
(such as community-based organizations already working on empowerment of
women) and training women's SHG leaders and barbers as peer
educators is an effective and culturally appropriate way to disseminate
comprehensive information on HIV/AIDS to low-literacy communities.
Similar models for reaching and empowering vulnerable populations should
be expanded to other rural areas, like Papua New Guinea. (15)

Community-Based Education Program

One approach to alleviating the stress on national health provision
is to expand the knowledge base at the community level with
contributions by lay health workers (LHWs). (16,17) In order to
accurately assess the impact of interventions, we should pay attention
to socioeconomic and behavioral aspects and to disease surveillance at
the local level. We need to marshal volunteers from within communities,
taking account of their problems and motivations to ensure interventions
incorporating two-way dialogue with the general populace to package
expertise in the medical/research community for lay consumption.
Community "gatekeepers," heads of households, and religious
and community-based leaders should also be included in the education
program to increase their level of awareness. It is especially important
to implement services for the prevention of mother-to-child HIV
transmission. (18,19) When facing limited awareness and accessibility to
high-risk groups, a strategy was developed to encourage members of the
high-risk population to assume a leadership role in the development and
implementation of the community-based program. (20,21) When designing an
education program, attention is focused on the segmentation of the
audience (urban, rural, urban slum) and messages, and on how appropriate
communication and educational strategies can be adopted to raise
awareness of AIDS. (22) Community participation, program activities, and
outreach strategies, including the development of educational materials
and media contacts, are key for the success of a community educational
program. (23-25) A family health awareness campaign (FHAC) has been
implemented and scaled up in India. (26,27)

Secondary School Peer Education Program

A peer education program was conducted among adolescents in a rural
area of Nigeria, to evaluate whether such programs promote HIV/AIDS
awareness in terms of knowledge, misconceptions, and behavior. (28) A
comparative case series (n = 250), cross-sectional structured survey (n
= 135), and focus group discussions (n = 80) were undertaken among
adolescents. In both the case series and structured survey, a
questionnaire was used to address socio-demographic factors, knowledge
on the transmission and prevention of HIV/AIDS, accessibility to
different sources of HIV/AIDS information, stigmatization, and sexual
behavior. Binary logistic regression was applied to compare responses
from the peer-educated and not peer-educated populations. The model was
adjusted for confounders. It was demonstrated that, among adolescents
receiving peer education, HIV/AIDS knowledge increased and
misconceptions and risky sexual behavior decreased when compared to
adolescents not receiving peer education. These differences were
apparent both over time (2005-2007) and cross-sectionally (2007). Peer
education in rural areas can be effective in HIV/AIDS prevention, by
positively influencing knowledge and behavior.

AIDS Awareness through Community Mobilization

Community Mobilization to Prevent HIV Transmission

The PRECEDE-PROCEED model for community planning and health
promotion to eliminate local disparities in HIV disease was adopted by a
coalition led by public health professionals. During the first year of
the project, discussion groups and other formative evaluation activities
maximized input from community members and community-based
organizations. Twelve of 53 ZIP code areas, which accounted for 73% of
reported AIDS cases among Black and Hispanic young adults (18 to 39
years) from 1994 through 1999, were selected as the primary sites for
intervention. (29) Horizontal outreach to residents, vertical outreach
to stakeholders and gatekeepers, strategic communication, and capacity
building and infrastructure development were chosen as the most
promising activities to promote behavioral and social change. Results
from baseline computer-assisted telephone-interview (CATI) surveys
completed with 2,011 community residents in 2001 and first-year
follow-up interviews with 2,381 residents in 2002 indicated that:
awareness of program efforts had increased from 5.4% in 2001 to 6.7% in
2002; recognition of the extent of the HIV/AIDS problem had increased
from 27.5% in 2001 to 35.3% in 2002; and participation in HIV prevention
efforts had increased significantly. Interventions were reaching the
target audience, informing young adults of the risks of HIV infection
and encouraging them to take ownership and action. Community KAP
(knowledge, attributed, practice) of AIDS prevention is critical.
(30-34)

Networking Communities in Fighting against AIDS

When combined with major social inequities, the AIDS epidemic in
Brazil becomes much more complex and requires effective and
participatory community-based interventions. (35) A civil society
organization, the Center for Health Promotion (CEDAPS), in the slum
communities (favelas) of Rio de Janeiro, Brazil, used a community-based
participatory approach in which 55 community organizations were
mobilized to develop local actions to address the increasing social
vulnerability to HIV/AIDS of people living in squatter communities. This
was achieved through on-going prevention initiatives based on the local
culture and developed by a Network of Communities. The community
movement has created a sense of "ownership" of social actions.
The fight against AIDS has been a mobilizing factor in engaging and
organizing communities and has contributed to raising awareness of
health rights. Local actions included targeting the determinants of
local vulnerability, as suggested by health promotion workers.

Serial Theme Education Programs

There have been successful experiences from the US. (36) During the
1987-90 period, five phases of new AIDS information materials were
released to the general public in the ARTA (America responds to AIDS)
campaign, including a national mailer. The five phases consisted of
"General Awareness: Humanizing AIDS" in October 1987,
"Understanding AIDS," the national mailout, in April 1988,
"Women at Risk/Multiple Partners, Sexually Active Adults" in
October 1988, "Parents and Youth" in May 1989, and
"Preventing HIV Infection and AIDS: Taking The Next Steps" in
July 1990. From planning to implementation to evaluation, ARTA is based
on well-established theory and practice. Initially, the campaign was a
response to an immediate crisis. It has evolved into the deliberate and
systematic development of objectives to combat a chronic problem. ARTA
represents one of the most comprehensive formative research processes in
the history of public service campaigns. The dynamic process of
carefully developing each new phase to include such important entities
as state and local health agencies and community-based organizations is
at least as important as the quality of the end materials. The
objectives of each new phase are based on the needs of the public and of
specific audiences. Maximum input from all relevant constituencies is
obtained to ensure that they support the campaign's objectives and
implementation strategy. Other special theme educational programs, such
as the "Focus on Kids" HIV Risk Reduction Program (37), and
the use of qualitative methodology in a remote Uganda community (38)
have had success.

Community-Based HIV Mobilization for VCT

Forty-eight communities in Tanzania, Zimbabwe, South Africa, and
Thailand (39), and in Ouagadougou, Burkina Faso (40) were randomized to
receive the intervention or receive clinic-based standard voluntary
counseling and testing (VCT) for comparison. The intervention included
changing community norms to increase awareness of HIV status and reduce
HIV-related stigma. Utilization of community-based HIV mobile VCT and
clinic-based standard VCT by the community at 3 sites was monitored to
assess differential uptake. Quality assurance procedures to evaluate
staff fidelity to the intervention were also developed. The provision of
mobile services, combined with appropriate support activities, may have
significant effects on the utilization of VCT. These findings also
provide early support for community mobilization as a strategy for
increasing testing rates.

CONCLUSION

Community-based interventions to promote HIV/AIDS awareness and
change risky behavior in special groups help to prevent the spread of
HIV/AIDS.

(27.) Aggarwal AK, Duggal M. Knowledge of men and women about
reproductive tract infections and AIDS in a rural area of north India:
impact of a community-based intervention. J Health Popul Nutr.
2004;22(4):413-9.